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Thursday, March 23, 2017

In the 1970s, Canadian psychologist Bruce Alexander and a group of colleagues at Simon Fraser University tested the widely believed hypothesis that drugs such as morphine are intrinsically addictive. They took two groups of rats and placed the first in the standard laboratory cages used at the time: small and cramped with little space to move and interact. The second they put in the ‘Rat Park’: a spacious enclosure filled with wood chips, platforms, running wheels and tin cans.

Alexander and his colleagues introduced two types of liquid for the rats to drink: water and morphine solution. The caged rats consumed significantly more morphine than their ‘Rat Park’ counterparts. Alexander and his colleagues concluded that there was something about the living conditions of the isolated rats that meant that they were more likely to drink the morphine; the ‘Rat Park’ rats tended to avoid it. Whilst these results have subsequently been disputed, it is an attractive allegory for drug consumption and addiction in humans.

Consider taking the ‘Rat Park’ allegory one step further. Instead of the heroin and morphine being supplied by criminal gangs, imagine it is medical professionals providing drugs users with their hit. The people who should be treating those who are addicted are fuelling their habits, and in some cases instigating them. This is not a futuristic dystopia, but a view of the contemporary United States healthcare system presented by psychiatrist Anna Lembke in Drug Dealer, MD: How Doctors were Duped, Patients got Hooked and Why it’s So Hard to Stop. Lembke describes how patients will travel from clinic to clinic to obtain prescriptions for opioids such as Vicodin or Oxycontin. Describing one of her patient’s interactions with a physician, we hear how ‘Jim’s encounter with the drug dealer pretending to be a doctor was the moment he realized he had become a drug addict pretending to be a patient’ (117).Image Credit: (woodleywonderworks CC BY 2.0)

So how did this situation come about? Lembke outlines a combination of factors. First, the emergence of chronic (as opposed to acute) pain as an entity to be feared and aggressively treated, followed by the marketing of opioids by the pharmaceutical companies for both. This has been compounded by a fragmented, de-personalised, mainly private healthcare system that prioritises profit over patient care.

Lembke argues that pain has come to be seen by modern medicine as something to be avoided at all costs: ‘pain is considered an almost intolerable sensation for patients to endure […] The pressure to treat pain has become so overwhelming that doctors who leave pain untreated are not just demonstrating poor clinical skills; they are viewed as morally compromised’ (42). In tandem has come the idea that pain in itself can be a disease. Lembke makes the case that what she calls ‘chronic pain syndromes’ are a contemporary phenomenon, claiming that the idea people could experience physical pain in the absence of a disease process or physical injury would previously have been an alien concept to most medical professionals.

As a treatment for acute pain and a substance to abuse, opiates are nothing new. Opium is known to have been used for millennia, and its potential for addiction was recognised (and exploited) by British merchants, leading directly to the Opium Wars of the mid-nineteenth century. Morphine’s more potent cousin, heroin (known medically as diamorphine), was first synthesised in 1874, and marketed by the German pharmaceutical company Bayer from 1898. Lembke describes the first US heroin epidemic at the turn of the twentieth century, which led Bayer to discontinue its production in 1913, and a second epidemic in the 1960s as US soldiers returned from Vietnam. In the US and Europe, these experiences led to caution amongst physicians in prescribing opiates for anything more than short-term use to patients experiencing the most severe pain.

Back in the US, Lembke also documents how unscrupulous academics, often funded by pharmaceutical companies, used cherry-picked and flawed evidence to launch a questionable new paradigm in pain medicine: that opioid painkillers were effective in the treatment of chronic pain. She quotes Dr Russell Pourtnoy, one of the cheerleaders for more liberal use of opioids in the 1990s and early 2000s: ‘because our primary goal was to de-stigmatise, we often left evidence behind’ (62, also available on YouTube). By then there was a variety of semi-synthetic and synthetic opioids such as Vicodin and Oxycontin being marketed to doctors and patients. Manufacturers claimed that these had fewer side effects than morphine. Unsurprisingly, these new formulations were also more expensive: in 2015 the global prescription opioids market was valued at almost $34 billion dollars.

One of the paradoxes of the US prescription opioid epidemic is that, like many addictions, it is hitting hardest those who can least afford the substances on which they are dependent. In a predominantly private healthcare system, how can those who are the poorest and least educated (and proportionally most affected) pay for their medications? Here, Lembke draws on the work of economists David Autor and Mark Duggan. In The Growth of the Social Security Disability Rolls: A Fiscal Crisis Unfolding, they examine the factors underlying the near-doubling of the number of US adults on Social Security Disability Insurance (SSDI) since 1984. They argue that congressional reforms in the 1980s ‘enabled workers with low mortality disorders such as back pain, arthritis and mental illness to more readily qualify for benefits’, leading to an increase in people claiming SSDI for conditions such as chronic pain. To this Lembke adds the 1996 US Welfare Reform Bill, which she believes provided an incentive for states ‘to move poor people to the disabled category to improve the state’s welfare numbers’ (93). Lembke believes that these have led to the creation of ‘Professional Patients’: people reliant on federally funded disability as their primary source of income (91). As for those unable to obtain opioids through medical channels, they are increasingly turning to heroin and other black market alternatives.

The final two chapters of Drug Dealer MD are devoted to ways to curb the current epidemic. The key complicating issue is the structure of the US healthcare system. It appears much easier to continue to prescribe opioids to an addicted patient with chronic pain, as insurance companies tend not to fund treatment for addictive disorders. Lembke describes the difficulty in persuading a patient’s insurance company to fund Suboxone, her chosen treatment for a patient’s opiate addiction: ‘the whole process required three days […] Had I written a prescription for an opioid painkiller […] Jim could have picked it up in the same hour’ (132).

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I am Stephen Darori onLinkedin, Facebook, Twitter,& many other places on the web.My previous surname was Drus ( Dziedrueszyck .in the 17th Century, Drus from 1856 amd Drus from 1907 ) It still is out of Israel. The American Family branch spell their name Drues. The English Family branch Druce. I hebrewaized my surname on 6th September 1986 to Dǻrori( דרורי in Hebrew, دا روري in Arabic). Dǻrori is a "Sparrow" in Biblical Hebrew. The "a' and the acute accent was added in 1987 for Branding Purposes. Ahad Ha'am ( Asher Ginsberg) an early Hebrew Poet wrote , " Cage a Sparrow and it will Die" and from here Eliezer ben Yehuda who revived the Hebrew Language added a metaphorical meaning for "Freedom" and "Liberty" .